Tetraplegia after complicated sigmoid polypectomy

Abstract

A 79-year-old man was admitted with a 6-week historyof low-grade fever, neck pain and progressive weakness.Eight weeks before admission, he underwent a colonos-copy for anal bleeding, and a voluminous 2-cm sessilepolyp in the sigmoid colon with signs of recent haem-orrhage was removed using snare cautery. This wascomplicated immediately by arterial bleeding. Haemosta-sis was achieved with the injection of 1:10 000epinephrine solution, argon plasma coagulation andhaemoclipping. Pathology revealed a low-grade tubulo-villous adenoma.Physical examination disclosed neck tenderness, flac-cid tetraplegia, C3 sensory level, hyperreflexia and loss ofanal tone. Blood cultures revealed methicillin-sensitiveStaphylococcus aureus (MSSA). Magnetic resonance imag-ing showed multilevel cervical spinal canal stenosis, septicarthritis of the right C3 ⁄4 facet joint and an anteriorepidural abscess extending between C3 and C5, causingspinal cord compression (Fig. 1). Echocardiographyshowed no vegetations. He was submitted to urgentdecompression laminectomy. Over the next few weeks,neurological recovery was poor.Bacteremia occurs in about 4% of colonoscopicprocedures, but it is asymptomatic. Transient systemicor distant infection is not considered a complication ofcolonoscopy, but the risk of bacteria entering the bloodstream to multiply at distant sites in susceptible hostsexists. The absence of data on the frequency ofcolonoscopy-related systemic infection may be relatedto the infrequency of cases and the difficulty inestablishing a temporal relationship, because patientsmay fail to report a previous procedure. There are,however, rare clinical reports of distant infectionsassociated with colonoscopy and polypectomy [1–5].Although their connection to such procedures may bebased only on circumstantial evidence, it should not beignored because of the high morbidity. It is also worthnoting that underlying colonic lesions per se are a riskfactor for distant infection.To our knowledge, there have been no previouscases of spinal infection complicating polypectomy.Moreover, spontaneous septic arthritis of facet jointsof the cervical spine is very rare in adult nondrug usersand St. aureus is the most implicated microorganism. Inthis case, inoculation of bacteria in the spine occurredduring the polypectomy-related transitory bacteremia.After the complete formation of septic arthritis andepidural empyema, the patient presented a full-blownclinical picture of secondary septicaemia. The significantbleeding requiring passage of several instruments andthe invasive haemostasis might be implicated in thespinal infection and may have been related to contam-ination of instruments, since MSSA is usually not foundin the normal intestinal flora. The physician should bealert of the possibility of infection after polypectomy toavoid delay in diagnosis that could lead to disastroussequences as in this case.